Self-perceived attitudes toward interprofessional collaboration and interprofessional education among different health care professionals in pediatrics

Interprofessional education (IPE) is the basis for interprofessional collaboration (IPC) in health care systems. It has beneficial effects for both patients and health care professionals. IPC is paramount for adequate care of patients and their families, especially in pediatrics. To determine the attitudes of medical doctors (n=121), nurses (n=15), psychologists (n=14), and social workers (n=19) toward IPE and IPC in a tertiary pediatric university teaching hospital, as well as the inpatient and outpatient settings in pediatrics, we developed a questionnaire with 21 items in four categories based on established questionnaires. All participants worked as part of interprofessional teams, and the overwhelming majority valued IPC highly. Most competencies important for IPC were acquired on the job. There was a substantial lack of interprofessional education, especially for medical doctors and psychologists. IPE still needs to be established as part of the undergraduate curriculum at German universities.


Introduction
Interprofessional education (IPE), defined as students from two or more professions learning together, about, and from each other, is a necessity for successful interprofessional collaboration (IPC) [1], [2], [3], [4]. The ability to work as part of an interprofessional team or even lead an interprofessional team is expected of university graduates soon after they start their career in the health care system, but so far interprofessional learning has not been established in the standard curriculum of German universities. The CanMeds role model strongly emphasizes the "collaborator" as a learning objective in medical education and has been adopted by the education systems in different countries, such as Switzerland, and by some universities in Sweden and the United Kingdom [5], [6], [7], [8]. IPE is highlighted in the recently adopted German National Competency-based Learning Objectives Catalogue in Medicine (NKLM) [9], [http://www.nklm.de]. The WHO Framework for Action on Interprofessional Education and Collaborative Practice states that IPE improves both IPC and health care outcomes [1], especially in terms of shorter hospital stays for patients, less medication use, and greater appreciation of different health care professionals [10], [11], [12]. Two Cochrane reviews show that IPE and IPC do have positive effects, but that these cannot be generalized for behavioral changes in healthcare professionals or patient outcomes [13], [14]. Especially in the specialized care of pediatric patients (i.e. developmental aspects, family surroundings and social care), IPC is part of the daily routine work and crucial to adequate and economic care for patients and their families [15], [16]. Insufficient data exist on where and when different health care professionals acquire competencies essential for IPC.

Aim
The aim of this study is to evaluate the attitudes of different health care professionals working in pediatrics toward IPE and IPC. We wanted to determine which competencies health care professionals acquired and whether those competencies were learned during undergraduate training or while performing day-to-day clinical work.

Methods
We reviewed different established tools that evaluate IPC, including the Readiness for Interprofessional Learning Scale (RIPLS) [17], the Generic Role Perception Questionnaire (GRPC) [18], the Interdisciplinary Education Perception Scale (IEPS) [19], and the Index of Interdisciplinary Collaboration (IIC) [20], [21]. Not all of these questionnaires have been validated in German. Some were too time-consuming due to a great number of questions, and not one questionnaire addressed all the questions we were aiming at. Consequently, we developed a questionnaire in German based upon the published questionnaires. We created a questionnaire comprising 21 items divided into four subcategories: interprofessional collaboration, interprofessional education, attitudes toward interprofessional collaboration in routine work, and visions for IPC and IPE, as well as six items on demographic data (see attachment 1). Possible answers were graded on 5 to 6-point Likert scales (for details please refer to the attachment 1). Two open-ended questions were asked concerning the future of IPC and IPE to supplement the quantitative part of the questionnaire with qualitative data. A main focus of the questionnaire was the evaluation of competencies important for IPC and IPE. The questionnaire was peer-reviewed and approved by colleagues with a master's degree in medical education and the Baden-Württemberg Competency Centre for Evaluation in Medicine in Freiburg, Germany. All attendees of the 2014 meeting of the Working Group for child protection in medicine (AG-KiM) in Freiburg, Germany, were asked to fill out the questionnaire, as were all medical staff at the Freiburg Centre for Pediatrics and Adolescent Medicine (ZKJ), a tertiary university teaching hospital. These two groups did not overlap. The AG-KiM members work nationwide in Germany in inpatient and outpatient pediatric settings. The questionnaire was provided in electronic form (Questback GmbH. Published 2015. EFS survey, version 10.5. Cologne) at the ZKJ and in printed form to the AG-KiM, the latter was then entered into a joint electronic database.

Statistics
Statistical analysis was performed with IBM SPSS Statistics for Windows, (Version 22.0. Armonk, NY: IBM Corp.). Paired samples t-tests, Kruskal Wallis tests, and one-way ANOVAS were used to determine significant differences, and Bonferroni correction for multiple testing was applied where appropriate. Qualitative evaluation of the openended responses was performed as deductive and inductive qualitative content analysis after Mayring [22].

Study population
A total of 168 completed questionnaires were returned. Of these, 116 participants were female, 48 were male, and four did not indicate their gender. A total of 121 medical doctors participated: fifty in the AG-KiM (return rate 50.5%) and 71 at the ZKJ (return rate 59.2%). Forty-seven participants who were not medical doctors included 15 nursing staff, 14 psychologists, 19 social workers, two teachers and five others (radiology assistant, doctor's assistant, psychotherapist, two unspecified). The eight participants indicating a dual education were allocated according to their highest academic degree. Only those groups with more than 10 participants were included in further analysis. Of the medical doctors, 74 (61.1%) were board-certified pediatricians, 34 had additional subspecialty certification in pediatrics. Twenty-eight (23.1%) physicians had ≤ four years of professional experience, 40 (33.1%) had four-10 years of work experience, and 53 (43.8%) had ≥ 10 years of work experience. The other health care professionals generally had more work experience, with 68.4% (n=13) social workers, 80% (n=12) nurses and 92.9% (n=13) psychologists having ≥ 10 years of work experience.

Interprofessional collaboration
IPC was reported to be part of the daily routine by almost all medical doctors. A total of 120 physicians (99.2%) worked together with other physicians frequently or very frequently. Frequent or very frequent collaboration with nursing staff was reported by 111 (91.7%), with social workers by 85 (70.2%), with physiotherapists by 73 (60.3%), with nursery-school teachers by 37 (30.5%), with psychologists by 36 (29.7%), with remedial teachers by 32 (26.4%), with teachers by 19 (15.7%), and with other health care professionals (e.g. midwives) by 17 (14%) of the physicians (see figure 1). In the AG-KiM, 92.9% of psychologists worked together with social workers, and 100% of social workers worked at least frequently with psychologists, whereas only 78.6% of psychologists and 78.9% of social workers worked frequently or very frequently together with nursing staff. Very frequent or frequent team decisions with other physicians were reported by 119 (98.3%), with nursing staff by 107 (88.4%), with psychologists by 87 (71.9%), with social workers by 61 (50.4%), with physiotherapists by 27 (22.3%), with remedial teachers by 21 (17.3%), with nursery-school teachers by 11 (9.1%), with teachers by 10 (8.3%), and with other health care professionals by 8 (6.6%) of the physicians (see figure 2). Medical doctors at the ZKJ (M=1.37, SD±0.54) did include nursing staff significantly more frequently in interdisciplinary decisions than did physicians in the AG-KiM (M=1.82, SD±1.35) (p=.032). Psychologists did not value nursing staff as highly as other health care professionals in interprofessional decisions ("nursing staff" (M=1.43, SD±0.76) vs. "other health care professions" (M=1.14, SD±0.36): p=.0203). Of all participants, 90.9% (153) stated that IPC in routine clinical work was "very helpful;" all but one of those remaining rated it as "helpful". The collaboration with different health care professions was deemed important for treatment success (see figure 3). IPC with other physicians was stated to be very helpful or helpful by 119 "Which professional groups are you working with, and how frequently, in your routine work? Please provide information for each professional group." The ranking was performed by pooling "very often" and "often." Figure 2: Frequency of medical doctors' decision-making with different health care professions. Participants were asked to answer: "How often do you make decisions in an interprofessional team? Please provide information for each professional group." The ranking was performed by pooling "very often" and "often." (98.3%), with psychologists by 117 (96.7%), with nursing staff by 116 (95.9%), with social workers by 100 (82.6%), with physiotherapists by 98 (80.9%), with nursery-school teachers by 77 (63.6%), with remedial teachers by 72 (59.5%), and with others by 7 (5.8%) of the participating physicians (see figure 3). No demographic factors (sex, work experience, affiliation to ZKJ or AG-KiM) or profession accounted for any differences.  1). By trend, psychologists did not acquire any of the competencies during undergraduate training but only Participants were asked to answer: "For successful treatment of the patient/client the interprofessional collaboration with the following professional groups is.... Please provide information for each professional group." The ranking was performed by pooling "very often" and "often." during work, whereas social workers mainly learned respect for other health care professionals, adequate terminology, and interprofessional collaboration in general during work. Nurses acquired all competencies apart from conflict management during undergraduate training. The self-assessed level of competence did not differ significantly between the professions.

Day-to-day interprofessional collaboration
In general, all participants demonstrated a high level of awareness of interprofessional collaboration. Work experience, affiliation with the AG-KiM or ZKJ, sex, or profession did not have any influence on this awareness. Between participating nurses, psychologists and social workers, no significant correlations could be determined concerning the acquisition of competencies and higher self-assessment or of the ability to work interprofessionally. This might be due to the relatively low numbers of participants in these groups.

Qualitative evaluation
Through deductive and inductive context analysis based on Mayring [22], we were able to identify four core competencies that the participants rated as being most important for the future of IPE and IPC, these being professional expertise, methodical expertise, social expertise, and personal competence. Professional expertise was mentioned as the basis of future IPE and IPC. Participants suggested using functioning structures in IPC (e.g. ethics committees, child protection services) as examples for IPE and establishing interprofessional lectures and courses. Methodical expertise (e.g. conflict management) was deemed important to cope with challenging situations; social competence to enable interaction in a social environment. Personal competence is comprised of the abilities to self-reflect and anticipate the consequences of actions undertaken in IPC.
Structural changes, for example in the clinical hierarchy or allotting more time for IPE and IPC, along with the possibility of interprofessional courses during undergraduate and postgraduate work, were also highlighted as essential.

Discussion
This is the first larger study that evaluates interprofessional education (IPE) and interprofessional collaboration (IPC) in the pediatric care setting. The overwhelming majority of participants did show a high level of awareness for IPC and ranked IPC as important for the clinical care of patients. Only for single items were we able to determine significant differences in attitudes that could be attributed to work experience, age, sex, working in a pediatric inpatient or outpatient setting. For example, less experienced medical doctors rated the importance of IPC as being higher than their more experienced peers did, and female medical doctors valued IPE more highly than their male colleagues in general, different health care professionals in pediatrics valued the role of IPE and IPC.

Interprofessional Collaboration
As expected, medical doctors most frequently worked together and made joint decisions with nursing stuff, more so in the inpatient pediatric setting. This is not surprising as pediatricians in ambulatory care in Germany traditionally do not work with qualified nurses but rather with physician's assistants. At the ZKJ, psychologists seem to play an important role in the interprofessional teams, so it is not surprising that this study showed a high level of collaboration with this profession. In the AG-KiM, psychologists and social workers did work significantly more with each other than with any other health care professionals, which is typical for many pediatric in-and outpatient settings in Germany. We were also able to show that competencies acquired during undergraduate training or during the professional career led to a higher appraisal of different professional groups and more collaboration with other professions in day-to-day work, something that is corroborated by the literature [13], [14]. The core competencies stated by participants, either by checking items or as commentary, are congruent with the competencies proposed by the expert panels on interprofessional collaboration [4], [7].

Interprofessional education
When comparing the results of the different professional groups, it must be kept in mind that the non-medical participants had their professional education mostly more than 10 years ago. The most important finding was the absence of structured IPE during undergraduate training and that significantly more participants acquired skills necessary for IPC in the course of their work. This correl-ates with findings concerning other professional groups. For example, only 43% of physical therapists (PT) and 50% of occupational therapists (OT) in Canada reported having received sufficient IPE [23]. Both our data and the literature may hint at a need for greater promotion of IPE as a basis on which IPC can gain support to initiate IPE programs, especially in medical schools and during undergraduate psychology, PT, and OT training. It will be interesting to see how today's students in healthcare-related professions rate their acquisition of IPC skills. Social workers and especially nurses seem to acquire more competencies important for IPC during undergraduate training. Interestingly, the participants rated the future importance of IPC as being higher than that of IPE. This does put an additional strain on junior staff in health care who will have to cope with their new role, continue to gain knowledge in their specialties, and at the same time focus on how to improve their interprofessional competencies [9], [24]. In Germany, the National Competency-based Catalogue of Learning Objectives in Medicine (NKLM) from 2015 does put emphasis on the acquisition of competencies, including those essential to IPC [9], [http://www.nklm.de].
The implementation of the NKLM into the curriculum of German medical schools should enable medical students and junior medical doctors to fulfill their roles in the interprofessional team more quickly and efficiently, to the benefit of patients and treatment outcomes. Initial projects to implement IPE in university courses in Germany include the bachelor's degree in interprofessional health care studies at Heidelberg and the program entitled, Longitudinaler Strang Interprofessionalität (Longitudinal Focus on Interprofessionalism), at Freiburg which include other health care professionals as well [25], [26]. It would be beneficial to analyze how IPE takes place and what exactly is learned in IPE during professional practice, as well as whether or not a theory of social learning could explain these aspects of IPE.

Limitations and outlook
This study has some limitations in the field of IPE and IPC as reported in other studies [13], namely the small number of participants and the heterogeneous study cohort with a predominance of female participants. Our project evaluates the attitudes toward IPE and IPC held by health care professionals working in pediatrics, as well as the acquisition of competencies important for IPE and IPC. Of all participants in our study, 72% were medical doctors making the interpretation of these results difficult. Further evaluation of the questionnaire is planned. An interesting long-term project will be evaluating the acquisition of competencies by future medical students as the NKLM [9], [http://www.nklm.de] is implemented in the coming years.

Conclusions
Interprofessional collaboration is an essential part of routine work in pediatrics and is valued highly by different health care professionals who seem to acquire interprofessional skills mostly during clinical work and in direct interaction with other professionals. There is a substantial lack of interprofessional education at German medical schools and universities that should be addressed urgently; initial projects are underway. Heidelberg und der "Longitudinale Strang Interprofessionalität" in Freiburg, welche auch Angehörige anderer Gesundheitsberufe einbeziehen [25], [26]. Es wäre hilfreich, zu analysieren, wie die IPE stattfindet, was genau innerhalb der interprofessionellen Ausbildung im Rahmen der beruflichen Tätigkeit erlernt wird und ob eine Theorie aus dem Bereich des sozialen Lernens diese Aspekte der interprofessionellen Ausbildung erklären könnte.